A proposal to grade the severity of early allograft dysfunction after liver transplantation

Paolo Salvalaggio, Rogerio Carballo Afonso, Guilherme Felga, Ben-Hur Ferraz-Neto, Paolo Salvalaggio, Rogerio Carballo Afonso, Guilherme Felga, Ben-Hur Ferraz-Neto

Abstract

Objective: To propose a grading system for early hepatic graft dysfunction.

Methods: A retrospective study from a single transplant center. Recipients of liver transplants from deceased donors, transplanted under the MELD system were included. Early graft dysfunction was defined by Olthoff criteria. Multiple cut-off points of post-transplant laboratory tests were used to create a grading system for early graft dysfunction. The primary outcome was 6-months grafts survival.

Results: The peak of aminotransferases during the first postoperative week correlated with graft loss. The recipients were divided into mild (aminotransferase peak >2,000IU/mL, but <3,000IU/mL); moderate (aminotransferase peak >3,000IU/mL); and severe (aminotransferase peak >3,000IU/mL + International Normalized Ratio ≥1.6 and/or bilirubin ≥ 10mg/dL in the 7th postoperative day) early allograft dysfunction. Moderate and severe early dysfunctions were independent risk factors for graft loss. Patients with mild early dysfunction presented with graft and patient survival comparable to those without graft dysfunction. However, those with moderate early graft dysfunction showed worse graft survival than those who had no graft dysfunction. Patients with severe early dysfunction had graft and patient survival rates worse than those of any other groups.

Conclusion: Early graft dysfunction can be graded by a simple and reliable criteria based on the peak of aminotransferases during the first postoperative week. The severity of the early graft dysfunction is an independent risk factor for allograft loss. Patients with moderate early dysfunction showed worsening of graft survival. Recipients with severe dysfunction had a significantly worse prognosis for graft and patient survival.

Conflict of interest statement

Conflict of interest: none.

Figures

Figure 1. Relationship of aminotransferase peak in…
Figure 1. Relationship of aminotransferase peak in the first week (A), bilirubin (B) and INR (C) at day 7 with 6-month allograft loss
Figure 2. Non-adjusted graft (A) and patient…
Figure 2. Non-adjusted graft (A) and patient (B) survival according to severity of EAD

References

    1. Merion RM. Current status and future of liver transplantation. Semin Liver Dis. 2010;30(4):411–421.
    1. Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe RA. The survival benefit of liver transplantation. Am J Transplant. 2005;5(2):307–313.
    1. Schaubel DE, Sima CS, Goodrich NP, Feng S, Merion RM. The survival benefit of deceased donor liver transplantation as a function of candidate disease severity and donor quality. Am J Transplant. 2008;8(2):419–425.
    1. Axelrod DA, Guidinger MK, Metzger RA, Wiesner RH, Webb RL, Merion RM. Transplant center quality assessment using a continuously updatable, riskadjusted technique (CUSUM) Am J Transplantat. 2006;6(2):313–323.
    1. Axelrod DA, Koffron AJ, Baker T, Al-Saden P, Dixler I, McNatt G, et al. The economic impact of MELD on liver transplant centers. Am J Transplant. 2005;5(9):2297–2301.
    1. Buchanan P, Dzebisashvili N, Lentine KL, Axelrod DA, Schnitzler MA, Salvalaggio PR. Liver transplantation cost in the model for end-stage liver disease era: looking beyond the transplant admission. Liver Transpl. 2009;15(10):1270–1277.
    1. Abecassis M. Making dollars and sense out of liver transplantation. Liver Transpl. 2009;15(10):1159–1161.
    1. Howard RJ. The challenging triangle: balancing outcomes, transplant numbers and costs. Am J Transplant. 2007;7(11):2443–2445.
    1. Neuberger J, Madden S, Collett D. Review of methods for measuring and comparing center performance after organ transplantation. Liver Transpl. 2010;16(10):1119–1128.
    1. Olthoff KM, Kulik L, Samstein B, Kaminski M, Abecassis M, Emond J, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl. 2010;16(8):943–949.
    1. Stockmann M, Lock JF, Malinowski M, Seehofer D, Puhl G, Pratschke J, et al. How to define initial poor graft function after liver transplantation? - a new functional definition by the LiMAx test. Transpl Int. 2010;23(10):1023–1032.
    1. Briceño J, Ciria R, la Mata M de, Rufián S, López-Cillero P. Prediction of graft dysfunction based on extended criteria donors in the model for end-stage liver disease score era. Transplantation. 2010;90(5):530–539.
    1. Silberhumer GR, Pokorny H, Hetz H, Herkner H, Rasoul-Rockenschaub S, Soliman T, et al. Combination of extended donor criteria and changes in the Model for End-Stage Liver Disease score predict patient survival and primary dysfunction in liver transplantation: a retrospective analysis. Transplantation. 2007;83(5):588–592.
    1. González FX, Rimola A, Grande L, Antolin M, Garcia-Valdecasas JC, Fuster J, et al. Predictive factors of early pós-operatório graft function in human liver transplantation. Hepatology. 1994;20(3):565–573.
    1. Greig PD, Woolf GM, Abecassis M, Forster J, Strasberg SM, Taylor BR, et al. Prostaglandin E1 for primary nonfunction following liver transplantation. Transplant Proc. 1989;21(2):3360–3361.
    1. Strasberg SM, Howard TK, Molmenti EP, Hertl M. Selecting the donor liver: risk factors for poor function after orthotopic liver transplantation. Hepatology. 1994;20(4 Pt 1):829–838.
    1. Deschênes M, Belle SH, Krom RA, Zetterman RK, Lake JR. Early allograft dysfunction after liver transplantation: a definition and predictors of outcome. National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. Transplantation. 1998;66(3):302–310.
    1. Johnson SR, Alexopoulos S, Curry M, Hanto DW. Primary nonfunction (PNF) in the MELD Era: An SRTR database analysis. Am J Transplant. 2007;7(4):1003–1009.
    1. Snoeijs MG, Wiermans B, Christiaans MH, van Hooff JP, Timmerman BE, Schurink GW, et al. Recipient hemodynamics during non-heart-beating donor kidney transplantation are major predictors of primary nonfunction. Am J Transplant. 2007;7(5):1158–1166.
    1. Lock JF, Schwabauer E, Martus P, Videv N, Pratschke J, Malinowski M, et al. Early diagnosis of primary nonfunction and indication for reoperation after liver transplantation. Liver Transpl. 2010;16(2):172–180.
    1. Uemura T, Randall HB, Sanchez EQ, Ikegami T, Narasimhan G, McKenna GJ, et al. Liver retransplantation for primary nonfunction: analysis of a 20-year single-center experience. Liver Transpl. 2007;13(2):227–233.
    1. Pepe MS, Longton G. Standardizing diagnostic markers to evaluate and compare their performance. Epidemiology. 2005;16(5):598–603.
    1. Feng S, Goodrich NP, Bragg-Gresham JL, Dykstra DM, Punch JD, DebRoy MA, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant. 2006;6(4):783–790.
    1. Health Resources and Services Administration Organ Procurement and Transplantation Network. [cited 2012 Ago 2];Allocation of liver [Internet] 2012 Available from: .
    1. Wiesner R, Edwards E, Freeman R, Harper A, Kim R, Kamath P, Kremers W, Lake J, Howard T, Merion RM, Wolfe RA, Krom R, United Network for Organ Sharing Liver Disease Severity Score Committee Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91–96.
    1. Silva HT, Jr, Felipe CR, Abbud-Filho M, Garcia V, Medina-Pestana JO. The emerging role of Brazil in clínical trial conduct for transplantation. Am J Transplant. 2011;11(7):1368–1375.
    1. Durand F, Renz JF, Alkofer B, Burra P, Clavien PA, Porte RJ, et al. Report of the Paris consensus meeting on expanded criteria donors in liver transplantation. Liver Transpl. 2008;14(12):1694–1707.
    1. Tector AJ, Mangus RS, Chestovich P, Vianna R, Fridell JA, Milgrom ML, et al. Use of extended criteria livers decreases wait time for liver transplantation without adversely impacting posttransplant survival. Ann Surg. 2006;244(3):439–450.
    1. Alkofer B, Samstein B, Guarrera JV, Kin C, Jan D, Bellemare S, et al. Extendeddonor criteria liver allografts. Semin Liver Dis. 2006;26(3):221–233.
    1. Merion RM, Goodrich NP, Feng S. How can we define expanded criteria for liver donors? J Hepatol. 2006;45(4):484–488.
    1. Renz JF, Kin C, Kinkhabwala M, Jan D, Varadarajan R, Goldstein M, et al. Utilization of extended donor criteria liver allografts maximizes donor use and patient access to liver transplantation. Ann Surg. 2005;242(4):556–63. discussion 563-5.
    1. Amin MG, Wolf MP, TenBrook JA, Jr, Freeman RB, Jr, Cheng SJ, Pratt DS, et al. Expanded criteria donor grafts for deceased donor liver transplantation under the MELD system: a decision analysis. Liver Transpl. 2004;10(12):1468–1475.
    1. Afonso RC, Hidalgo R, Paes AT, Zurstrassen MP, Fonseca LE, Pandullo FL, et al. Impact of cumulative risk factors for expanded criteria donors on early survival after liver transplantation. Transplant Proc. 2008;40(3):800–801.
    1. Humar A, Ramcharan T, Kandaswamy R, Gillingham K, Payne WD, Matas AJ. Risk factors for slow graft function after kidney transplants: a multivariate analysis. Clin Transplant. 2002;16(6):425–429.
    1. Francoz C, Prié D, Abdelrazek W, Moreau R, Mandot A, Belghiti J, et al. Inaccuracies of creatinine and creatinine-based equations in candidates for liver transplantation with low creatinine: impact on the model for end-stage liver disease score. Liver Transpl. 2010;16(10):1169–1177.
    1. Simons JP, Ng SC, Hill JS, Shah SA, Bodnari A, Zhou Z, et al. In-hospital mortality for liver resection for metastases: a simple risk score. J Surg Res. 2009;156(1):21–25.
    1. Jacob M, Lewsey JD, Sharpin C, Gimson A, Rela M, van der Meulen JH. Systematic review and validation of prognostic models in liver transplantation. Liver Transpl. 2005;11(7):814–825.

Source: PubMed

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